This is a presentation I did for the OTAT program at Cuyahoga Community College on flexor and extensor tendon lacerations. I also discuss, briefly, the application of certain aspects of occupational therapy's domain as outlined in the OTPF. I collected data from scholarly as well as non-scholarly resources. I hope you find this to be helpful.

1. Flexor and Extensor
Tendon Lacerations
By Chevahlyan Dozier

2. DESCRIPTION
O Tendon = part of the muscle that attaches
the muscle to bone.
O Transfers forces generated by muscle to
bone; produces movement at joint.
O Lacerations occur when the tendons
experience a traumatic cut.

3. ANATOMY & PHYSIOLOGY
Flexor tendons that
bend fingers and wrist
Extensor tendons that
extend fingers and
wrist
O flexor digitorum
profundus and
superficialis
O flexor pollicis longus
O flexor carpi radialis
and ulnaris
O Palmaris longus
O extensor digitorum
communis
O extensor indicis proprius
O extensor digitorum
minimi
O abductor pollicis longus
O extensor pollicis brevis
and longus
O extensor carpi ulnaris
O extensor carpi radialis
brevis and longus

4. Abbreviation Full Name Function
APL Abductor pollicis longus Abduction of thumb
EPB Extensor pollicis brevis Extension of thumb proximal phalanx
ECRL
ECRB
Extensor carpi radialis longus/brevis Extends and abducts hand
EPL Extensor pollicis longus Extends thumb IP joint
EDC
(4 tendons: II - V)
Extensor digitorum communis Extends digits II - V
EIP Extensor indicis proprius Extends digit II
EDM (EDC) Extensor digitorum minimi (quinti) Extends digit V
ECU Extensor carpi ulnaris Extends and abducts hand

5. Abbreviation Full Name Function
FDL Flexor pollicis longus Thumb flexion
PL Palmaris longus Flexion of wrist
FCU Flexor carpi ulnaris Flexion and adduction of hand
FDP Flexor digitorum profundus flexion of distal interphalangeal joints
and helps wrist flexion
FDS Flexor digitorum superficialis Flexion of proximal interphalangeal
joints and flexion of proximal
phalanges at metacarpophalangeal
joints
FCR Flexor carpi radialis Flexion and abduction of hand at
wrist

6. Flexor Tendon Injury
Zones
1: flexor digitorum profundus
distal to insertion of flexor
digitorum superficialis
2: insertion of flexor digitorum
superficialis to proximal edge of
A1 pulley (“No Man’s Land”)
3: proximal edge if the A1 pulley
to distal edge of carpal tunnel
4: within the carpal tunnel
5: proximal to the carpal tunnel

7. Extensor Tendon
Injury Zones
O Extensor
tendons are
divided into 8
zones
O Zones 1,3 and 5
lie over the DIP,
PIP and MCP
joints

8. ETIOLOGY
Common mechanisms of
injury include, but are not
limited to:
“Fight Bite” injury
O sharp object direct
laceration (broken glass,
kitchen knives or table
saws)
O crush injury
O avulsions
O burns
O animal or human bites
O suicide attempts
O motor vehicle accidents

9. SIGNS & SYMPTOMS
O Unable to bend one or more finger joints
O Pain when bending finger/s
O Open injury to hand (e.g., cut on palm side of
hand, particularly in area where skin folds as
fingers bend)
O Mild swelling over joint closest to fingertip
O Tenderness along effected finger/s on palm side of
hand

10. OTHER COMPLICATIONS
O adhesions
O ruptures
O Infections
O postoperative edema and
inflammation
O wound dehiscence
O attenuation
O joint or soft tissue
contractures
O nerve and blood vessel
damage
O pain
O delayed rupture/failure of
tendon repair
O delayed healing due to
underlying medical
conditions
O Mallet finger deformity
O Boutonniere deformity
O Lumbrical plus
O Bowstringing
O Swan neck deformity
O Quadriga syndrome
O Finger cascade
O Extensor lag
O Trigger finger

12. DETECTION
O History and physical
O Examination of wound
O Use of bedside ultrasonography in ER (more sensitive and
specific than physical examination)
O Wound exploration techniques or MRI.
O 3-view x-ray must be done (except most benign) to rule out
foreign bodies or bony injury.
O Radiographs to evaluate for possible fractures or
dislocations (blunt trauma cases)

13. HISTORY
O History of tendon reconstruction can be traced
back to the times of Hippocrates and Galen.
O Galen (131-201 AD) stated that tendons were
composed of both ligaments and nerves. He
warned that suturing tendons would lead to
pain, twitching, and eventual convulsions.
O Was not refuted until 1682, when Meekren
observed that tendons are insensitive and
described the successful repair of
incompletely severed tendons.

14. MEDICAL MANAGEMENT
O Immediate surgical repair and wound debridement
O Immobilizing immediately following surgery
O Analgesics (Vicodin and Percocet)
O Nonsteroidal anti-inflammatories (NSAIDs) are generally
not prescribed as they can delay healing.
O Antibiotics may be prescribed as a post-operative
precaution.
O Hand therapy (2-4 week post-op; hand therapy timeline
and program determined by surgeon)

15. What can a therapist do?
O Evaluate the client’s injury following care by an orthopedist to coordinate
treatment plans and determine the course of intervention.
O Analyze the client’s environment at home and work to identify potential barriers
to the client’s performance
O Fabricate a protective splint for the injured part of the hand and teach the client
how to manage daily activities while wearing the splint
O Recommend a home exercise program that will facilitate healing and optimum
use of the hand
O Apply techniques to reduce swelling, prevent further injury, care for wounds,
and improve movement
O Show the client how to complete activities safely and independently while the
hand is being rehabilitated
O Incorporate the client’s goals and desires into the treatment plan
The American Occupational Therapy Association, Inc.

16. FLEXOR TENDON
MANAGEMENT
3 methods of post-op flexor tendon management are
Immobilization, controlled passive motion, and
early active motion

17. IMMOBILIZATION
O Complete immobilization of tendon for 3 ½ weeks after
surgery
O May not yield consistently good results due to production of
scar adherence
O May lead to a greater incidence of tendon rupture
O May be necessary if other injuries are present (e.g., a
fractured phalanx that cannot be moved)
O May be selected if patient appears unable to participate fully
in treatment (e.g., child or a person with cognitive
impairments)

18. CONTROLLED PASSIVE
MOTION
O Durand and Houser protocol allows 3 to 5 mm of tendon
excursion after repair
O On 3rd postoperative day, patient begins twice-daily exercise
regimen of passive flexion and extension (6 to 8 motions per
tendon)
O Keep wrist flexed and MCPs in 70 degrees of flexion
O After 4 ½ weeks, protective dorsal splint is removed and rubber
band traction is attached to a wristband.
O Active extension and passive flexion are done 1 additional week
and gradually increased over next several weeks.
O Found sufficient to prevent adherence of the repaired tendons

19. EARLY ACTIVE MOTION
O Kleinhert and Washington protocols use early active extension but passive
flexion
O Indian and MAMTT (minimal-active muscle-tendon tension) protocols allow early
gentile supervised active flexion of tendon
O Rubber bands are attached to fingernails of the involved digits
O Dorsal blocking splint with MCP joints held in ~ 60 degrees of flexion and
PIPs in gentile flexion
O Patient wears splint 24 hours a day for 3 weeks and is instructed to actively
extend fingers several times a day in splint, allowing rubber bands to pull
fingers into flexion
O Patient must be able to fully extend IP joints actively within splint to prevent
joint contractures
O Splint is removed at 3 weeks, depending on the surgeon’s judgment
O Method minimizes scar adhesions while enhancing tendon nutrition and
blood flow

21. POSTACUTE FLEXOR
TENDON REHAB
O Once active flexion is begun out of splint (after postoperative management), patient
should be instructed in exercises to facilitate differential tendon gliding
O Wehbe recommends 3 positions—hook fist, straight fist, and composite fist
O Tendon glide exercises should be repeated 10x’s in each position, 2-3x’s daily
O Isolated exercises to assist tendon gliding may be performed with a blocking splint or
by using opposite hand
O MCP joint is held in extension during blocking, so intrinsic muscles that act on it cannot
overcome power of repaired flexor tendons
O After 6 to 8 weeks, passive extension may be started (cylindrical plaster splint or volar
finger splint may be necessary to correct flexion contracture at PIP joint)
O After ~ 8 weeks, patient may begin light resistive exercises, light ADL, and other
activities; patient must avoid lifting with or applying excessive resistance to affected
hand
O Activities such as working with soft clay, woodworking, and macramé are excellent

24. EXTENSOR TENDON
MANAGEMENT
3 current treatment approaches to extensor tendon
rehabilitation are immobilization, early controlled
passive mobilization, and early active motion

25. IMMOBILIZATION
O Keeps the tendon in a shortened position
through splinting or casting
O Tendons immobilized for 3 weeks
O In week 4, gentle active motion of the repaired
tendon is introduced
O Rehabilitation depends on zone of injury

26. IMMOBILIZATION
INJURIES IN ZONES
PROXIMAL TO MCPs
INJURIES IN ZONES
DISTAL TO MCPs
O May be immobilized for 3
weeks.
O Afterwards, finger may be
placed in removable volar
splint between exercise
periods for additional 2 weeks
O Progressive ROM after 3
weeks
O If full flexion is not regained
rapidly, dynamic flexion may
be started after 6 weeks.
O Require a longer period of
immobilization (usually 6
weeks)
O A progressive exercise
program is then initiated
O Dynamic splinting during
day and static splinting at
night to maintain
extension.

27. EARLY PASSIVE MOTION
O Reverses protocol for the flexor tendons
O Extensors are held in extension by dynamic, gentle
rubber band traction, and the patient is allowed to
actively flex the fingers—passively moving the
repaired extensor tendons
O Splints must have dorsal component governing
flexion to inhibit overstretching or rupture of the
extensor tendon
O Facilitates tendon strength and can prevent the
scarring that ultimately limits motion and function

28. EARLY ACTIVE MOTION
O Early active short arc program (developed by
Evans) allows tendon to actively move 3 days
after surgery
O Therapist must take care to ensure stress
applied by early active motion does not
overpower strength of surgical repair
O Splinting program is complex and specific and
requires a skilled occupational therapist

29. What can the patient do?
O Implement a home exercise program recommended by the
occupational therapist
O Learn how to improve coordination to increase the use of his
or her hand under the supervision of an occupational therapist
O Strengthen the hand and progress toward full use of the hand
O Set short- and long-term rehabilitation terms upon consulting
an occupational therapist and other health professionals
O Learn how to perform daily activities, such as dressing,
grooming, and driving, in a safe manner while the hand is
being rehabilitated
The American Occupational Therapy Association, Inc.

30. PRECAUTIONS &
CONTRAINDICATIONS
O Consider any fracture, pulley, nerve and/or artery repairs that
may require longer immobilization phase or other
modifications to program
O Assess patient’s cognitive status to determine ability to
understand and comply with complex home program
O Monitor for signs of infection; report positive immediately
O It is advised to wait at least 72 hours before initiating any
active motion of the repaired tendon
O Do not add load over and above amount needed to initiate
tendon gliding.

31. more PRECAUTIONS &
CONTRAINDICATIONS
PATIENT INFORMATION
O Keep your hand elevated at all times (particularly
important during the early recovery period)
O Therapist will advise when this is no longer necessary.
O Carefully follow the exercise regime.
O Do not remove the splint under any circumstance.
O For any problems with the splint such as discomfort or
poor fitting, please contact a hand therapists.
O Do not attempt to adjust the splint yourself.

32. even more PRECAUTIONS &
CONTRAINDICATIONS
PATIENT INFORMATION
O Do not use the injured hand for anything other than
performing your exercise regime.
O Do not use the hand for driving for at least 10 weeks
following surgery.
O Do not hyperextend the PIP joint (this would overstretch the
repaired tendons)
O Do not operate machinery of any sort whilst wearing a
protective splint.
O Do not participate in any sporting activities.

33. PROGNOSIS
O Depends on cause, type, site, and extent of tendon laceration; length of
time between injury and repair; and type of repair.
O If damaged tendon can be restored to normal length with adequate
strength, good function should return.
O Fractures, infection, involvement of more than one tendon, or concomitant
injuries to hand make it more difficult to achieve complete restoration of
finger and hand function.
O Staged reconstruction of tendon repair following initial surgery is often
necessary for complex cases and results in prolonged incapacitation.
O Proper postoperative splinting, hand therapy, and excellent compliance with
treatment plans are essential
O If normal tendon function cannot be completely restored or if there are
concomitant injuries to joints, manual dexterity may be compromised.

34. PROGNOSIS cont...O Tendons do not heal as well as other body tissues
O Smoking may affect tendon strength.
O Late tendon repair is not very successful and sometimes not even possible.
O Delay can result in the formation of scar tissue and retraction of tendons
O Other factors that can affect recovery include age, tissue quality, strength and
health
O Healing time for tendon repair will take 8-12 weeks but restoration of function
and ability to accept full activity, load and stress can take up to one year.
O Full resistance and normal work activities may resume at 3 months after
surgery
O “Functional” to “excellent” result = minimal extension lag at PIP and DIP joints
and finger can flex to palm.

35. OCCUPATIONAL THERAPY
FRAMEWORK APPLICATION
Aspects of Occupational Therapy’s Domain

36. AREAS OF OCCUPATION
O Patient would experience difficulty in various areas of occupation,
including bathing, toilet hygiene, dressing, driving, administering
medications, meal preparation, feeding and eating, resting and
sleeping
O Work hardening may be indicated pending work demands and level
of injury
O Patient should be educated in one-handed techniques to lessen
occupational disruption.
O Family may be available for support
O May experience anxiety about recovery timeframe and uncertainty
of the prognosis.
O If recovery is less than complete, patient’s job should be analyzed
for adaptation potential

37. PERFORMANCE SKILLS
O Motor skills (manipulating, stabilization, coordination, etc.) are
disrupted.
O Abilities to move, transport, lift, calibrate, and grip are lost in affected
extremity due to medical precautions.
O May experience reduced activity tolerance due to increased demands
of performing activities one-handed.
O Skills related to handling and holding are challenging because the
involved hand cannot be used to stabilize.
O Disturbances in timing of tasks resulting from one-handed performance.
O May need to rely on others more.
O Relationship with others may change due to temporary dependent
occupational status.

38. PERFORMANCE PATTERNS
O Habits, routines, roles and rituals may be
altered
O It will take longer to perform tasks
O Previous habits and routines may not be
possible while tendon healing (e.g., adhering
to daily housework schedule)
O Loss of worker role and changes in
performance of parent and household
maintainer roles may be psychologically
devastating

39. CLIENT FACTORS
O Neuromusculoskeletal and movement-related functions
most obviously affected
O Disuse and neglect of finger (especially index finger) are
common and should be prevented.
O Limited strength and range or motion in affected hand
while the tendon is healing
O No reason to expect any cognitive deficits
O May be depressed over injury and anxious about future
O May affect experience of self and ability to cope with
situation.

40. CONTEXT & ENVIRONMENT
O Decreased ability to carry things for long distances or up and down
stairs
O May experience difficulty negotiating and navigating physical
environment
O Decisions regarding workforce involvement may negatively affect
occupational identity and self-worth
O Relationships with spouse may become strained
O Relationships with systems (e.g., economic or institutional) may be
negatively impacted.
O Inability to work everyday can increase risk for isolation and
occupational alienation.

41. GUIDE for INTERVENTION
O Biomechanical practice approach is most appropriate.
O Goals of this approach:
O evaluate specific physical limitations in ROM, strength,
and endurance
O restore these functions
O prevent or reduce deformity
O Biomechanical principles are also applied in ergonomics
and work hardening
O Limitations: approach is reductionistic rather than holistic

42. PROFESSIONAL
ORGANIZATIONS
O International Federation of Societies for
Surgery of the Hand (IFSSH)
O American Association for Hand Surgery
(AAHS)
O American Society for Surgery of the Hand
(ASSH)

43. CONCLUSION
O Persons experiencing tendon injury in hand may experience
difficulties with performance in all areas of occupation
O Every person’s injury is different and rate of recovery
depends on the severity of the injury as well as other client
factors
O Occupational therapy practitioners can provide rehabilitation
intervention that enables the hand to function well and
prevent further injury
O Must have understanding of tendon anatomy of the hand and
of the type of surgical repair
O Must have good communication with the surgeon.

44. Thank you
:)

45. Glossary
O Paradoxical extension (“Lumbrical Plus Finger”): when the patient
attempts to flex the fingers, the relatively tight lumbrical will cause PIP
extension
O No man’s land injury: injury to the area between the distal palmar crease
and the insertion of the flexor digitorum superficialis (zone II); this is
considered the most difficult to treat because the tendons lie in their
sheaths in this area beneath the fibrous pulley system, and any scaring
will cause adhesions.
O Quadriga effect: uneven tension applied to the common muscle belly of
the flexor profundus tendons due to advancement of tendon leading to
limited flexion of the remaining profundus tendons
O Extensor lag: incomplete extension
O Tenolysis: surgical clearing of surrounding tendon scar
O Adhesions: fibrous bands that form between tissues and organs, often as
a result of injury during surgery; may be thought of as internal scar tissue
that connect tissues not normally connected.

46. Glossary
O Rupture: the tearing apart of a tissue
O Wound dehiscence: the parting of the sutured lips of a surgical
wound
O Attenuation: a reduction in thickness and density due to
stretching
O Delayed rupture: a tendon rupture which does not immediately
occur after injury; may also refer to tendon rupture which occurs
after surgical repair of the tendon (not at site of repair).
O Mallet finger deformity: an involuntary flexion of the distal
phalanx of a finger caused by avulsion of the extensor tendon
O Swan neck: DIP hyperflexion with PIP hyperextension

47. Glossary
O Avulsion: an injury in which a body structure is forcibly detached
O Boutonniere deformity: a chronic flexion of the PIP joint and
extension of the DIP joint
O Bowstringing: a loosening of the tendon from the finger
allowing tendon taking shortest distance between remaining
pulleys
O Trigger finger: difficulty flexing or extending the finger caused
by catching, snapping or locking of the involved finger flexor
tendon, associated with dysfunction and pain
O Finger cascade: Excessive trimming and advancement of the
profundus tendon leading to flexed position of finger compared
with other fingers.

48. RESOURCES
O www.twinboro.com
O emedicine.medscape.com
O www.mdguidelines.com
O www.aota.org
O www.brighamandwomens.org
O www.cuh.org.uk
O www.brighamandwomens.org
O ajot.aotapress.net

49. References
Al-Qattan, M. (2007). Surgical treatment and results in 17 cases of open lacerations of the
extensor hallucis longus tendon. Journal of Plastic, Reconstructive & Aesthetic
Surgery, 360-367. doi:10.1016/j.bjps.2006.05.003
American Occupational Therapy Association. (2008). Occupational Therapy Practice
Framework: Domain & Process 2nd Edition. American Journal of
Occupational Therapy, 62, 625-683.
American Occupational Therapy Association, Inc. (2007, May 16). Intervention for Tendon
Injuries. Retrieved from American Occupational Therapy Association:
http://www.aota.org/Consumers/consumers/Work/Tendon/35184.aspx

50. References
Barbara Hall, H. L. (2010). Research Scholars Initiative—Comparing Three Postoperative Treatment
Protocols for Extensor Tendon Repair in Zones V and VI of the Hand. The American
Journal of Occupational Therapy, 64, 682–688. doi:10.5014/ajot.2010.09091
Benjamin C Wood, M. (2012, March 9). Flexor Tendon Lacerations . Retrieved from Medscape
Reference: Drugs, Diseases & Procedures:
http://emedicine.medscape.com/article/1286303-overview#a04
Department of Rehabilitation Services . (2007). Standard of Care: Flexor /Extensor Tendon Laceration
of the Forearm, Wrist, Digits. Retrieved from Brigham and Women's Hospital: A Teaching
Affiliate of Harvard Medical School:
http://www.brighamandwomens.org/About_BWH/default.aspx

51. References
Ginard I Henry, M. (2012, January 31). Extensor Tendon Lacerations . Retrieved from
Medscape Reference: Drugs, Diseases & Procedures:
http://emedicine.medscape.com/article/1286225-overview#a04
Poole, S. E. (2013). Acute Hand Injuries: Introduction to Tendon Injuries. In M. B. Early,
Physical Dysfunction Practice Skills for the Occupational Therapy Assistant
(pp. 604-609). St. Louis: Mosby.
R. G. Xie, Y. C. (2008). The Gliding Force and Work of Flexion in The Early Days After
Primary Repair of Lacerated Flexor Tendons: An Experimental Study. The
Journal of Hand Surgery, 192–196. doi:10.1177/1753193408087035